Match each patient's clinical presentation with the most appropriate next step in management or pharmacotherapy.
- A 31-year-old woman with 4 weeks of severe depression and anhedonia; history reveals a past 6-day episode of decreased need for sleep, grandiosity, and impulsive spending.Initiate quetiapine or lurasidone monotherapy.
- A 74-year-old man with 1 month of profound depression, delusions of poverty, and refusal to eat or drink resulting in severe dehydration and acute kidney injury.Admit for urgent electroconvulsive therapy (ECT).
- A 45-year-old woman with major depressive disorder, previously well-controlled on paroxetine, who was recently diagnosed with breast cancer and initiated on adjuvant tamoxifen therapy.Cross-taper paroxetine to an agent with minimal CYP2D6 inhibition (e.g., venlafaxine).
- A 60-year-old man developing major depressive disorder 4 weeks after a myocardial infarction; he requires pharmacotherapy but has a left ventricular ejection fraction of 35%.Initiate sertraline monotherapy.
- A 21-year-old man presenting with 2 weeks of depressed mood, profound fatigue, hypersomnia, and increased appetite, which began 4 days after abruptly discontinuing his prescribed high-dose amphetamines.Provide supportive care and reassurance; symptoms are typically self-limiting.
Cevap
The clinical scenarios map to specific management branch points: bipolar depression (quetiapine/lurasidone), life-threatening psychotic depression (ECT), CYP2D6 drug interactions (switch from paroxetine), post-myocardial infarction depression (sertraline), and amphetamine withdrawal (supportive care).
Each clinical vignette tests a critical, high-yield branch point in the management of depressive presentations. The 31-year-old patient has unrecognized bipolar II disorder, requiring bipolar-specific agents (quetiapine/lurasidone) rather than SSRI monotherapy to avoid mood destabilization. The 74-year-old patient has severe psychotic depression with life-threatening starvation, making ECT the treatment of choice due to its rapid onset and high efficacy. The 45-year-old patient is taking tamoxifen, which requires CYP2D6 for activation; paroxetine is a strong CYP2D6 inhibitor and must be switched to an agent with minimal inhibition like venlafaxine. The 60-year-old patient requires depression treatment post-myocardial infarction, where sertraline is the evidence-based SSRI of choice due to excellent cardiovascular safety. The 21-year-old patient is experiencing amphetamine withdrawal, which mimics atypical depression but is a substance-induced, self-limiting condition that requires only supportive care.
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Anahtar Kavram
The precise management of depressive disorders requires careful differentiation of unipolar vs. bipolar illness, recognition of life-threatening emergencies requiring ECT, mitigation of critical drug interactions (e.g., CYP2D6), understanding of cardiovascular safety, and distinguishing primary depression from substance withdrawal.